📋 Key Information Summary
- Nasal discharge character is the single most useful bedside clue: clear watery suggests allergic/viral rhinitis; thick purulent suggests acute bacterial sinusitis; unilateral bloody/foul discharge mandates urgent exclusion of foreign body or malignancy.
- Allergic rhinitis (AR) affects approximately 1 in 5 Australians and is the most common chronic nasal disorder managed in primary care; intranasal corticosteroids (INCS) are first-line pharmacotherapy.
- Acute bacterial sinusitis (ABS) should be diagnosed when symptoms persist ≥ 10 days without improvement, or worsen after initial improvement ("double sickening"); first-line antibiotic is amoxicillin 500 mg TDS for 5–7 days.
- Nasal polyps are associated with chronic rhinosinusitis, asthma, and aspirin-exacerbated respiratory disease (AERD); intranasal corticosteroids are the mainstay; biologic therapy (dupilumab) is PBS-listed for severe cases.
- Epistaxis — most bleeds originate from the anterior septum (Kiesselbach's plexus); first-aid measures (lean forward, compress soft part of nose × 10 min) control > 90% of cases.
- Recurrent or posterior epistaxis in patients on anticoagulants or with hepatic/renal disease warrants ENT referral; posterior packing carries aspiration and airway risk and should be performed in hospital.
- Hyposmia / anosmia may follow viral upper respiratory infections (including COVID-19), head trauma, or signal intracranial pathology; persistent unilateral anosmia with nasal obstruction warrants urgent imaging.
- Nasal tumours — squamous cell carcinoma is the most common sinonasal malignancy; unilateral nasal obstruction, epistaxis, facial pain, or cranial nerve palsy in an adult > 40 years should prompt urgent ENT referral (2-week wait).
- Australian-specific considerations: CA-MRSA is prevalent in remote Aboriginal and Torres Strait Islander communities and must be considered when purulent nasal/sinus infections fail initial therapy; nasal swab culture guides decolonisation regimens.
- Allergic rhinitis and asthma frequently co-exist (up to 80% of asthmatics have AR); poorly controlled AR worsens asthma outcomes — always assess both conditions together per ASCIA guidelines.
- Epistaxis in children is almost always anterior and benign; recurrent bilateral epistaxis with easy bruising warrants FBC and coagulation screen to exclude bleeding diathesis.
- MBS item 104 (specialist consultation) applies for ENT referrals; bulk-billing incentives apply for ATSI patients and those in rural/remote areas under the Practice Incentives Program (PIP).
Introduction & Australian Epidemiology
Nasal disorders encompass a broad spectrum of conditions ranging from self-limiting infectious rhinitis to life-threatening malignancies. They represent one of the most common reasons for primary care consultation in Australia, with allergic rhinitis alone accounting for an estimated 4.6 million GP encounters annually. The Australian climate — characterised by high pollen loads in temperate zones, dust in arid regions, and humidity in tropical north Queensland — creates a distinctive allergen profile that influences disease prevalence and seasonality.
The economic burden is substantial: direct healthcare costs for allergic rhinosinusitis in Australia exceed .2 billion per year when pharmacy, GP, specialist, and hospital costs are combined. Indirect costs from absenteeism and reduced workplace productivity further inflate this figure. Epistaxis accounts for approximately 1 in 200 emergency department presentations nationally, with peaks during winter (dry mucosa) and hay-fever season (mucosal inflammation).
This guideline provides an evidence-based approach to the diagnosis and management of common nasal disorders in Australian primary care and specialist practice, aligned with Therapeutic Guidelines (eTG), ASCIA, RACGP, and Australasian Society of Clinical Immunology and Allergy recommendations.
Red-flag symptoms requiring urgent ENT referral: Unilateral nasal obstruction with epistaxis in adults > 40 years; new-onset unilateral anosmia; cranial nerve palsy (especially V2, VI); non-healing nasal septal perforation; saddle-nose deformity; persistent purulent rhinorrhoea refractory to standard therapy. These may indicate malignancy, granulomatosis with polyangiitis (GPA), or other systemic disease.
Typical Symptoms & Nasal Discharge Characteristics
A systematic approach to nasal symptoms begins with characterising the discharge (rhinorrhoea), as colour, consistency, laterality, and associated features narrow the differential diagnosis rapidly.
Discharge Character — Clinical Correlation
| Discharge Type | Appearance | Likely Diagnosis | Key Features |
|---|---|---|---|
| Clear, watery | Thin, copious, bilateral | Allergic rhinitis; viral rhinitis; CSF leak | Allergic: sneezing, itch, conjunctivitis. CSF: unilateral, post-trauma, "halo sign" |
| Mucoid (white/grey) | Thick, tenacious | Chronic rhinosinusitis; vasomotor rhinitis | Post-nasal drip, hyposmia, facial pressure |
| Mucopurulent (yellow/green) | Thick, coloured, bilateral or unilateral | Acute bacterial sinusitis; adenoiditis (children) | ≥ 10 days of symptoms or worsening after initial improvement |
| Purulent (frank pus) | Yellow-green, foul smell possible | Chronic sinusitis with nasal polyps; dental abscess eroding into maxillary sinus | Unilateral foul: dental origin or foreign body (children) |
| Bloody (epistaxis) | Bright red or dark clots | Epistaxis; nasal tumour; granulomatous disease | Unilateral recurrent: suspect structural/mass lesion |
| CSF rhinorrhoea | Clear, salty taste, unilateral | Skull base defect (trauma, surgery, spontaneous) | Positive "halo sign" on filter paper; β-2 transferrin assay confirms |
Associated Symptoms
- Nasal obstruction: Mucosal oedema (allergic, infectious), structural (deviated septum, turbinate hypertrophy), mass (polyps, tumour)
- Sneezing: Allergic rhinitis (morning predominance), viral rhinitis (first 1–2 days), vasomotor rhinitis (irritant triggers)
- Facial pain/pressure: Sinusitis (maxillary — cheek/tooth; frontal — forehead; ethmoid — between eyes; sphenoid — occipital/retro-orbital)
- Hyposmia/anosmia: CRS with polyps, post-viral (including SARS-CoV-2), head trauma, neurodegenerative disease
- Post-nasal drip: Allergic rhinitis, CRS, vasomotor rhinitis — contributes to chronic cough
Clinical pearl: Unilateral symptoms in any category (obstruction, discharge, bleeding) are always more concerning than bilateral symptoms and warrant earlier investigation to exclude foreign body (children), tumour, or structural pathology.
Allergic Rhinitis & Sinusitis
Allergic Rhinitis (AR)
Allergic rhinitis is an IgE-mediated inflammatory disorder of the nasal mucosa triggered by aeroallergens. In Australia, the most prevalent allergens are ryegrass pollen (temperate regions), house dust mites (Dermatophagoides pteronyssinus and D. farinae), moulds (Alternaria, Cladosporium), and pet dander. AR is classified by the ARIA (Allergic Rhinitis and its Impact on Asthma) framework:
Mild
Intermittent AR
Symptoms < 4 days/week or < 4 consecutive weeks. Normal sleep, daily activities, work/school, and sport unaffected.
Setting: GP / pharmacy self-care
Moderate–Severe
Persistent AR
Symptoms ≥ 4 days/week and ≥ 4 consecutive weeks. At least one of: impaired sleep, daily activities, work/school, or sport affected.
Setting: GP — step-up pharmacotherapy; consider ENT/allergy referral
Diagnostic Approach
- Clinical diagnosis supported by characteristic history (sneezing, rhinorrhoea, nasal itch, obstruction) and typical allergen exposure pattern
- Skin prick testing (SPT) or serum-specific IgE (RAST) to confirm allergen sensitisation — available through allergists and some GP practices with allergy training
- Anterior rhinoscopy: pale, oedematous turbinates with thin clear secretions
- Nasal endoscopy (ENT): if polyps suspected, atypical features, or refractory symptoms
Pharmacological Management — Stepwise Approach
Mometasone furoate nasal spray
Nasonex® · Generic · Intranasal corticosteroid (INCS)
Adult dose
2 sprays (50 µg/spray) each nostril OD for 2–4 weeks, reduce to 1 spray each nostril OD for maintenance
Paediatric dose
2–11 years: 1 spray each nostril OD. ≥ 12 years: adult dose
Route
Intranasal
Duration
Continuous during allergen exposure; may be used long-term
Renal adjustment
Nil — negligible systemic absorption
Hepatic adjustment
Nil required
PBS status
✔ PBS General Benefit
Fexofenadine hydrochloride
Telfast® · Generic · Non-sedating antihistamine (H1 antagonist)
Adult dose
120–180 mg PO OD
Paediatric dose
6 months–2 years: 15 mg PO BD. 2–11 years: 30 mg PO BD. ≥ 12 years: adult dose
Route
Oral
Renal adjustment
eGFR 30–50: 60 mg OD; eGFR < 30: 60 mg OD with caution
Hepatic adjustment
No specific recommendation — use with caution
PBS status
✔ PBS General Benefit
Azelastine / Fluticasone propionate nasal spray
Dymista® · Combination INCS + antihistamine
Adult dose
1 spray each nostril BD (137 µg azelastine / 50 µg fluticasone per spray)
Paediatric dose
≥ 12 years: adult dose. Not recommended < 12 years
Renal adjustment
Nil required
PBS status
⚡ PBS Authority Required — when INCS alone inadequate after ≥ 4 weeks
Ipratropium bromide nasal spray
Atrovent Nasal® · Anticholinergic
Adult dose
2 sprays (21 µg/spray) each nostril BD–TDS for watery rhinorrhoea
Paediatric dose
≥ 6 years: 1–2 sprays each nostril BD–TDS
PBS status
✔ PBS General Benefit
ASCIA recommendation: INCS should be started 1–2 weeks before the pollen season for patients with seasonal AR. Counsel patients on correct spray technique (aim laterally, away from septum) to maximise efficacy and minimise epistaxis.
Allergen Immunotherapy
Sublingual immunotherapy (SLIT) or subcutaneous immunotherapy (SCIT) should be considered when pharmacotherapy provides inadequate symptom control or when there is a clear allergen trigger confirmed on SPT/RAST. Australian programs typically target ryegrass, house dust mite, or Alternaria. Referral to a clinical immunologist/allergist is required. MBS item 106 applies.
Sinusitis
Acute Rhinosinusitis (ARS)
Most episodes of acute rhinosinusitis are viral (common cold) and self-limiting (7–10 days). Acute bacterial sinusitis (ABS) complicates 0.5–2% of viral upper respiratory infections.
Diagnostic Criteria for ABS (IDSA 2012 / eTG)
1
Persistent symptoms
Nasal discharge or daytime cough ≥ 10 days without improvement from onset
2
Severe onset
Purulent nasal discharge + high fever (≥ 39°C) + facial pain/tooth pain for ≥ 3–4 consecutive days at illness onset
3
Double sickening
Worsening symptoms (new onset fever, headache, increase in discharge) after initial improvement of a viral URI
Antibiotic Therapy for ABS
Amoxicillin
Amoxil® · Generic · Aminopenicillin
Adult dose
500 mg PO TDS for 5–7 days (eTG); extend to 10–14 days if slow response
Paediatric dose
30–50 mg/kg/day PO in 3 divided doses for 5–7 days
Renal adjustment
eGFR 10–30: 500 mg BD; eGFR < 10: 500 mg OD
PBS status
✔ PBS General Benefit
Amoxicillin–clavulanate
Augmentin® · Generic · β-lactam / β-lactamase inhibitor
Adult dose
875/125 mg PO BD for 5–7 days (high-dose formulation)
Paediatric dose
45 mg/kg/day (amoxicillin component) PO in 2 divided doses
Renal adjustment
eGFR 10–30: 500/125 mg BD; eGFR < 10: 500/125 mg OD
PBS status
✔ PBS General Benefit
Doxycycline
Doxy® · Generic · Tetracycline
Adult dose
200 mg PO OD day 1, then 100 mg PO OD for 5–7 days total
Paediatric dose
≥ 8 years: 2 mg/kg/day PO BD (max 100 mg BD) day 1, then 2 mg/kg/day OD
Renal adjustment
Not required
PBS status
✔ PBS General Benefit
Adjunctive Measures for Sinusitis
- Intranasal saline irrigation (0.9% or hypertonic): evidence supports improved symptom clearance; available OTC (FESS®, Flo Sinus Care®)
- Intranasal corticosteroids: Fluticasone or mometasone nasal spray — reduces mucosal oedema, particularly in AR-associated sinusitis
- Short-course oral corticosteroids: Prednisolone 25–50 mg daily for 5–7 days may be considered in severe CRSwNP or when polyps cause significant obstruction
- Oral decongestants (pseudoephedrine): Short-term use (≤ 5 days) for severe congestion; contraindicated in hypertension, cardiovascular disease, and within 14 days of MAOIs
Chronic Rhinosinusitis (CRS)
CRS is defined as symptomatic sinus inflammation lasting ≥ 12 weeks. It is subdivided into CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). Australian prevalence is approximately 10–12%. Diagnosis requires ≥ 2 of: nasal obstruction, anterior/posterior rhinorrhoea, facial pressure/pain, hyposmia/anosmia, plus either endoscopic or CT evidence of inflammation. Management involves prolonged INCS, saline irrigation, and ENT referral for endoscopic sinus surgery (ESS) if medical therapy fails after ≥ 3 months.
Nasal Polyps & Epistaxis
Nasal Polyps
Nasal polyps are benign, oedematous, semi-translucent grape-like projections arising from the paranasal sinus mucosa, most commonly from the ethmoid sinuses. They affect 1–4% of the adult population and are rare in children (consider cystic fibrosis if polyps found in a child).
Associations
- Asthma — up to 40–70% of CRSwNP patients have coexisting asthma
- Aspirin-exacerbated respiratory disease (AERD / Samter's triad): asthma + nasal polyps + NSAID/COX-1 sensitivity; present in 7–15% of asthmatic adults with polyps
- Allergic fungal rhinosinusitis — especially in atopic patients in tropical/subtropical Australia
- Cystic fibrosis — nasal polyps found in 10–40% of CF patients; bilateral
- Primary ciliary dyskinesia
Management of Nasal Polyps
1
INCS — First-line
Mometasone 200 µg BD or fluticasone propionate 200 µg BD nasal spray; ≥ 8–12 weeks before assessing response. Intra-polyp injection may be used by ENT specialists.
2
Short-course oral corticosteroids
Prednisolone 25–50 mg PO OD for 5–7 days (eTG) for acute exacerbations with significant obstruction. Limit to 2–3 courses/year due to cumulative ADRs.
3
Biologic therapy
Dupilumab (Dupixent®) — anti-IL-4Rα monoclonal antibody. PBS-listed (Authority Required) for severe CRSwNP inadequately controlled by INCS ± surgery. Dose: 300 mg SC fortnightly. Significant reduction in polyp size and improvement in olfaction and SNOT-22 scores.
4
Endoscopic sinus surgery (ESS)
Refer to ENT when medical therapy fails. Functional ESS opens sinus ostia and removes polyps under direct endoscopic vision. Recurrence rate is 40–60% at 5 years, hence ongoing INCS post-surgery is standard practice.
Red flag — unilateral polyp: A unilateral nasal polyp in an adult may represent an inverting papilloma (pre-malignant, 5–15% malignant transformation) or esthesioneuroblastoma. Unilateral polyps must always be biopsied under ENT guidance and are not suitable for empirical medical management.
Epistaxis
Epistaxis (nosebleed) is classified by location: anterior (90–95%) from Kiesselbach's plexus on the nasal septum, and posterior (5–10%) from branches of the sphenopalatine or ethmoid arteries. Posterior bleeds are more common in elderly patients, those on anticoagulants, and those with uncontrolled hypertension.
Aetiology
| Category | Common Causes |
|---|---|
| Local | Digital trauma (nose picking — most common in children), dry air/heating, allergic rhinitis, nasal septal deviation, foreign body, INCS use, nasal septal perforation, tumour |
| Systemic | Anticoagulant/antiplatelet therapy (warfarin, DOACs, aspirin, clopidogrel), liver cirrhosis/coagulopathy, thrombocytopenia, hereditary haemorrhagic telangiectasia (HHT/Osler-Weber-Rendu), hypertension (association debated but may exacerbate), vasculitis |
Stepwise Management of Epistaxis
1
First aid (patient self-care)
Sit upright, lean slightly forward, firmly compress the soft (cartilaginous) part of the nose against the midline septum for 10–15 minutes continuously. Avoid swallowing blood. Apply ice pack to nasal bridge. Spit out any blood in the mouth.
2
Chemical cautery
After achieving haemostasis, identify the bleeding point. Apply silver nitrate (75%) stick to the anterior septum for 5–10 seconds; bilateral cauterisation must be avoided (risk of septal perforation).
3
Anterior packing
Nasal tampon (Merocel®, Rapid Rhino®) or ribbon gauze impregnated with fusidic acid ointment. Leave in situ 24–48 hours. Prescribe prophylactic antibiotics (amoxicillin 500 mg TDS or co-trimoxazole) to prevent toxic shock syndrome.
4
Posterior packing / balloon tamponade
For posterior bleeds unresponsive to anterior measures. Requires hospital admission and continuous pulse oximetry (risk of hypoxia and cardiac arrhythmia). ENT specialist procedure.
5
Endoscopic surgical management
Endoscopic sphenopalatine artery ligation (ESPAL) or anterior/posterior ethmoid artery ligation for refractory cases. Angioembolisation by interventional radiology is an alternative.
Anticoagulant management during epistaxis: Do not routinely discontinue anticoagulants for simple anterior epistaxis. For severe/recurrent bleeds, consult the prescribing physician. INR should be checked in patients on warfarin — target INR 2.0–3.0 (or 2.5–3.5 for mechanical valves). For DOACs, timing of last dose is critical — do not reverse without haematology advice.
Disorders of Smell & Nasal Tumours
Disorders of Smell (Dysosmia)
Olfactory dysfunction is broadly classified as quantitative (hyposmia — reduced; anosmia — absent; hyperosmia — enhanced) or qualitative (parosmia — distorted perception; phantosmia — olfactory hallucination). In Australia, post-viral olfactory loss (including post-COVID-19) is now the most common cause, followed by CRSwNP and post-traumatic olfactory dysfunction.
Common Aetiologies
| Mechanism | Causes | Typical Presentation |
|---|---|---|
| Conductive (transport) | Allergic rhinitis, CRS, nasal polyps, septal deviation, turbinate hypertrophy | Bilateral smell loss; improves when obstruction relieved (e.g., decongestant trial) |
| Sensorineural (epithelial) | Post-viral (SARS-CoV-2, influenza, parainfluenza), toxic exposure (smoking, industrial chemicals), medications (intranasal zinc, methotrexate) | Acute onset following URI; may recover over 6–12 months; parosmia common during recovery |
| Neural (central) | Head trauma, neurodegenerative disease (Parkinson's, Alzheimer's), intracranial tumours (olfactory groove meningioma, frontal lobe glioma), epilepsy (uncinate fits) | Gradual or sudden onset; may be unilateral; associated neurological signs |
Investigation and Management
- Bedside testing: Assess each nostril separately using coffee, peppermint, or vanilla; standardised tools include the Sniffin' Sticks test or University of Pennsylvania Smell Identification Test (UPSIT) — available through ENT and neurology clinics
- Nasal endoscopy: Evaluate for polyps, masses, or mucosal disease
- MRI brain (with gadolinium): Indicated for unilateral anosmia, suspected intracranial pathology, or post-traumatic loss with focal neurological signs
- Post-viral olfactory training: Sniff 4 essential oils (rose, eucalyptus, lemon, clove) for 20 seconds each, twice daily, for ≥ 12 weeks. Evidence supports modest improvement in olfactory scores. Free resources available through Fifth Sense (UK) and adapted by ASCIA
- Intranasal corticosteroids: May benefit conductive and some post-viral cases; high-volume sinonasal rinses with budesonide (off-label) used by ENT for CRS-related hyposmia
- Alpha-lipoic acid (600 mg PO OD): Limited evidence for post-viral anosmia; may be trialled for 3 months
Post-COVID-19 olfactory dysfunction: Affects 40–65% of SARS-CoV-2 infections in the acute phase; 5–10% have persistent symptoms beyond 12 months. Most recover within 6 months. Olfactory training is the best-supported intervention. Intranasal corticosteroid sprays have not shown consistent benefit in RCTs for post-COVID anosmia specifically.
Nasal Tumours
Primary sinonasal tumours are rare, accounting for < 1% of all malignancies in Australia. Benign tumours are more common than malignant. A high index of suspicion is required as early symptoms are non-specific.
Benign Tumours
| Tumour | Key Features | Management |
|---|---|---|
| Inverting papilloma | Most common benign sinonasal tumour. Unilateral nasal obstruction, arises from lateral nasal wall. 5–15% malignant transformation to SCC. | Complete surgical excision (wide local excision via ESS). Long-term endoscopic follow-up essential. |
| Haemangioma | Red/blue mass on septum (capillary) or lateral wall (venous/cavernous). Recurrent epistaxis. | Surgical excision or laser ablation. |
| Ossifying fibroma | Slow-growing bony tumour of the mandible or maxilla; may extend into sinuses. | Surgical excision. |
| Juvenile nasopharyngeal angiofibroma (JNA) | Highly vascular tumour in adolescent males. Unilateral nasal obstruction + recurrent profuse epistaxis. CT/MRI shows characteristic bowing of posterior maxillary wall. | Pre-operative angioembolisation + surgical resection. Refer to paediatric ENT or skull-base centre. |
Malignant Tumours
| Tumour | Prevalence | Key Features | Management |
|---|---|---|---|
| Squamous cell carcinoma (SCC) | Most common sinonasal malignancy (~50–60%) | Unilateral nasal obstruction, epistaxis, facial pain, cheek swelling. Associated with hardwood dust (occupational), nickel, leather dust. | Surgery + adjuvant radiotherapy. MDT at tertiary centre. |
| Adenoid cystic carcinoma | 10–15% of sinonasal malignancies | Slow-growing; perineural invasion (V2, V3) is hallmark. Late recurrence (10–20 years). | Surgery + radiotherapy. Lifelong surveillance. |
| Esthesioneuroblastoma (olfactory neuroblastoma) | Rare (~3–5%) | Arises from olfactory epithelium at skull base. Unilateral nasal obstruction, epistaxis, anosmia. Bimodal age distribution (young adults + 50–60 years). | Craniofacial resection + radiotherapy ± chemotherapy. Kadish staging. |
| Mucosal melanoma | Rare (~3–5%) | Darkly pigmented (or amelanotic) mass. Aggressive with early metastasis. | Surgery + immunotherapy (checkpoint inhibitors). Refer melanoma MDT. |
| Non-Hodgkin lymphoma (NHL) | ~5–10% | NK/T-cell lymphoma (nasal-type) — more common in Asian/Indigenous Australian populations. Midline destructive lesion, "lethal midline granuloma". | Chemoradiotherapy. Refer haematology MDT. |
Urgent referral criteria for suspected sinonasal malignancy (2-week wait): Any adult (> 40 years) with unilateral nasal obstruction + epistaxis; new unilateral cranial nerve palsy (especially V1, V2, VI); non-healing nasal septal ulcer; expanding facial mass; persistent bloody nasal discharge unresponsive to standard management. Arrange CT ± MRI of sinuses and refer to ENT with head-and-neck oncology expertise.
Staging and Imaging
- CT sinuses (non-contrast): First-line for suspected structural/mass lesion; demonstrates bony erosion, involvement of orbit/skull base
- MRI with gadolinium: Superior for soft-tissue characterisation, intracranial extension, perineural spread, and orbital involvement. Essential for staging
- PET-CT: For staging of malignant sinonasal tumours; assesses regional and distant metastases
- Biopsy: Must be performed under ENT guidance (endoscopic); avoid blind biopsy due to risk of bleeding and incomplete sampling. JNA is typically not biopsied (imaging diagnosis) due to haemorrhage risk.
Investigations
Investigations for nasal disorders should be guided by clinical context. The majority of acute presentations (viral rhinitis, simple anterior epistaxis) require no laboratory or imaging workup.
GP — In Clinic
Anterior rhinoscopy
Visualisation of anterior nasal cavity using speculum and headlight. Identifies septal deviation, polyps, mucosal oedema, discharge character, bleeding points. No special equipment beyond ENT set.
GP — In Clinic
Nasal endoscopy (flexible)
Some GP practices with ENT interest; more commonly performed by ENT specialists. MBS item 106 (specialist). Direct visualisation of middle meatus, osteomeatal complex, and posterior nasal cavity.
GP — In Clinic
Skin prick testing (SPT)
Available in allergist clinics and some GP practices with allergy training. Battery includes HDM, grasses, moulds, pet dander, cockroach. Results in 15–20 minutes. MBS item 71030 (specialist/allergist).
GP — Pathology
Serum-specific IgE (RAST/CAP)
In-vitro allergen-specific IgE testing. Useful when SPT contraindicated (severe dermatographism, cannot stop antihistamines). Available through major labs (Sullivan Nicolaides, Douglass Hanly Moir, Pathology QLD). MBS item 71131.
GP — Pathology
Nasal swab — microscopy, culture, sensitivities
For refractory sinusitis, suspected CA-MRSA, or suspected diphtheria/other atypical infection. Essential in ATSI remote communities with high MRSA prevalence. Available through all major Australian pathology providers.
GP — Pathology
FBC, coagulation profile (INR, APTT, fibrinogen)
For recurrent epistaxis, suspected bleeding diathesis, thrombocytopenia, or anticoagulant monitoring. Bulk-billed at all Australian pathology labs.
Imaging — Referral
CT sinuses (non-contrast)
Gold standard for chronic rhinosinusitis diagnosis and surgical planning. Identifies mucosal thickening, polyps, bony erosion, anatomical variants. Available at most radiology practices. MBS item 56001.
Imaging — Referral
MRI brain/sinuses with gadolinium
For suspected intracranial extension, perineural spread, or olfactory groove pathology. Available at major radiology centres and hospitals. MBS item 63090.
Specialist
Nasal biopsy (endoscopic-guided)
For suspected malignancy, granulomatous disease (GPA, sarcoidosis), or atypical infection. Performed by ENT specialist. Histopathology via anatomical pathology.
Specialist
β-2 transferrin assay (CSF confirmation)
For suspected CSF rhinorrhoea. Collected in sterile container, sent to reference laboratory (e.g., PathWest WA, SA Pathology). High sensitivity and specificity for CSF.
Empirical Therapy
Empirical treatment decisions are guided by clinical presentation and likelihood of aetiology. Most acute nasal complaints are managed symptomatically before diagnostic confirmation.
Viral rhinosinusitis (common cold)
Paracetamol/ibuprofen PRN; saline irrigation; intranasal oxymetazoline × 3–5 days max
Self-limiting 7–10 days
No antibiotics. Avoid oral decongestants > 5 days (rhinitis medicamentosa risk).
Acute bacterial sinusitis (mild–moderate)
Amoxicillin 500 mg PO TDS
5–7 days
Add INCS (mometasone/fluticasone). If β-lactam allergy: doxycycline 200 mg day 1 then 100 mg OD. If atypical: add clarithromycin 500 mg BD.
Acute bacterial sinusitis (severe / high-risk)
Amoxicillin–clavulanate 875/125 mg PO BD
7–10 days
Consider IV if systemic signs (fever > 39°C, periorbital oedema, neurological symptoms). CT to exclude orbital/intracranial complications.
Allergic rhinitis (first presentation)
INCS (mometasone 200 µg/day or fluticasone 200 µg/day) + oral non-sedating antihistamine PRN
Ongoing / seasonal
Counsel on correct spray technique. Add SLIT/SCIT if inadequate response after 4–8 weeks. Refer allergy/immunology.
Anterior epistaxis (simple)
First aid (lean forward, compress 10–15 min) → silver nitrate cautery if visible bleeding point
Single event
Naseptin® cream (chlorhexidine + neomycin) BD to affected nostril for 10 days to promote mucosal healing. Check BP; review anticoagulants.
Nasal polyps — initial management
INCS (mometasone 200 µg BD or fluticasone 200 µg BD) + short course prednisolone 25–50 mg OD × 5–7 days
INCS ≥ 12 weeks; oral steroids for flare only
Refer ENT if no improvement. Check for AERD (aspirin sensitivity). Assess asthma control concurrently.
Monitoring
- Allergic rhinitis: Review at 4–8 weeks after initiating INCS; assess symptom control (ARIA classification), nasal obstruction severity, impact on sleep/work/asthma. Step down if well controlled; step up (add antihistamine, combination spray, or refer for immunotherapy) if persistent.
- Acute bacterial sinusitis: Review at 48–72 hours if no improvement or worsening; consider alternative antibiotic or imaging. Repeat review at 7 days to confirm resolution.
- Chronic rhinosinusitis: Assess at 3-monthly intervals using validated symptom scores (SNOT-22). CT at baseline and post-operatively. Monitor for polyp recurrence after ESS.
- Nasal polyps on dupilumab: Monitor at 16 weeks (first assessment point), then 6-monthly. Assess SNOT-22, NPS (Nasal Polyp Score), olfaction, asthma control (if concurrent), and eosinophil count.
- Recurrent epistaxis: Monitor haemoglobin if frequent bleeds. Review anticoagulant appropriateness. Screen for hereditary haemorrhagic telangiectasia (HHT) if recurrent nosebleeds with telangiectasia and family history (Curacao criteria).
- Post-surgical (ESS): Endoscopic surveillance at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months post-surgery, then annually if CRSwNP. Ongoing INCS is mandatory.
- Sinonasal malignancy post-treatment: Clinical examination + nasal endoscopy every 3 months for 2 years, then every 6 months for 3 years, then annually. CT/MRI per oncology protocol.
Special Populations
Pregnancy
Rhinitis of pregnancy: Affects up to 30% of pregnant women due to hormonal mucosal congestion. Diagnosis of exclusion (no allergen triggers, onset in 2nd/3rd trimester).
Safe medications: Saline irrigation is first-line. Budesonide nasal spray (Rhinocort Aqua®) is Category B1 in pregnancy — preferred INCS. Loratadine or cetirizine are the preferred oral antihistamines (Category B1).
Avoid: Pseudoephedrine (Category B2 — teratogenic in animal studies; use only if benefit outweighs risk). Oxymetazoline nasal spray — avoid chronic use.
Epistaxis may be more common in pregnancy due to hypervolaemia and mucosal congestion. Silver nitrate cautery is safe.
Paediatrics
Foreign body: Common in children 1–5 years. Unilateral, foul-smelling, purulent or bloody discharge. Do not probe blindly — refer to ED/ENT for removal under direct vision.
Adenoid hypertrophy: Major cause of nasal obstruction in children. Mouth breathing, snoring, hyponasal speech. Assess for obstructive sleep apnoea (OSA). Adenoidectomy ± tonsillectomy if significant.
Allergic rhinitis: Uncommon < 2 years; increases in school-age children. First-line: INCS (mometasone approved ≥ 3 years; fluticasone approved ≥ 4 years). Cetirizine liquid ≥ 1 year; loratadine syrup ≥ 2 years.
Nasal polyps in children: Consider cystic fibrosis (sweat test) and primary ciliary dyskinesia (nasal NO, genetic testing) if bilateral polyps.
Intranasal decongestants (oxymetazoline) should be avoided in children < 6 years due to risk of systemic absorption and CNS depression. Antibiotic dosing for sinusitis uses weight-based calculations.
Elderly
Posterior epistaxis: More common in elderly patients and more difficult to manage. Hypertension, anticoagulants (warfarin, DOACs, aspirin, clopidogrel), and mucosal atrophy are contributing factors. Lower threshold for ENT referral and admission.
Nasal polyposis: AERD triad may present for the first time in later life. Careful NSAID history required.
Sinonasal malignancy: Peak incidence 55–65 years. Any new unilateral nasal symptom should raise suspicion. Urgent CT + ENT referral.
Elderly patients may have atrophic rhinitis (ozaena) — dry, crusted nasal mucosa with foul smell. Managed with saline irrigation and topical emollients. Antihistamines with anticholinergic properties should be avoided (confusion, urinary retention risk).
Renal Impairment
Amoxicillin: Dose reduction required in eGFR < 30 (see drug card above). Amoxicillin–clavulanate: reduce dose if eGFR < 30.
Fexofenadine: Reduce to 60 mg OD if eGFR 10–50. Primarily renally excreted.
INCS: No dose adjustment needed — negligible systemic absorption.
Patients on dialysis with CRS may have altered mucosal immunity. Consider nasal swab cultures for CA-MRSA if recurrent sinusitis in the context of vascular access devices.
Hepatic Impairment
Coagulopathy: Hepatic impairment predisposes to epistaxis due to reduced clotting factor synthesis and thrombocytopenia. Check INR, APTT, platelets. Consider vitamin K 10 mg IV if INR elevated.
Antibiotics: Amoxicillin–clavulanate: risk of cholestatic hepatitis; use amoxicillin alone if mild liver disease. Doxycycline: no significant hepatic dose adjustment.
INCS are safe in hepatic impairment. Loratadine and cetirizine should be used with caution in severe hepatic failure (reduced clearance).
Immunocompromised
Expanded differential: Invasive fungal sinusitis (Aspergillus, Mucorales — especially in uncontrolled diabetes/DKA or neutropenia), atypical mycobacteria, CMV, HSV. This is an ENT/emergency.
Invasive fungal sinusitis: Presents with facial pain, fever, black eschar on nasal endoscopy, rapid orbital/cranial invasion. Requires emergency surgical debridement + IV antifungals (liposomal amphotericin B). Mortality 50–80%.
HIV: CRS is more common and severe. Low threshold for nasal swab (bacterial, fungal, AFB). Consider granulomatous disease (GPA, sarcoidosis).
Wegener's granulomatosis (GPA) commonly presents with ENT manifestations — saddle-nose deformity, septal perforation, bloody nasal crusting. c-ANCA/PR3 testing should be performed in patients with refractory CRS and systemic features.
Aboriginal and Torres Strait Islander Health
Aboriginal and Torres Strait Islander Health Considerations
Nasal and sinus disease disproportionately affects Aboriginal and Torres Strait Islander Australians, particularly those living in remote and very remote communities. Otitis media with effusion (OME) and upper respiratory tract infections are among the most common childhood conditions, and chronic rhinosinusitis in adults is frequently complicated by CA-MRSA colonisation and recurrent antibiotic-resistant infections.
Clinical alert: Any ATSI patient with chronic nasal symptoms, non-healing nasal septal ulcer, or progressive midline nasal destruction must be urgently assessed for nasal NK/T-cell lymphoma (nasal-type), which has a higher prevalence in some Indigenous populations. This tumour can mimic GPA ("lethal midline granuloma"). Urgent biopsy + haematology referral is essential.
📚 References
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